Medicare Compliance & Reimbursement

Get the facts to boost your excision reimbursement

When your physician performs lesion excisions, don't forget that you may be able to access the musculoskeletal (20000-series) codes, or you could seriously undercut your reimbursement for these procedures.

When you report an excision procedure, such as a lipoma (fatty tumor) removal, consider reporting either the codes for benign lesion excision (11400-11471) or the codes for musculoskeletal soft-tissue excision.

Your code choice depends on the excision's depth and, just as important, the specificity of the physician's documentation, says Jeffrey Weinberg, MD, director of the Clinical Research Center, Department of Dermatology, at St. Luke's-Roosevelt Hospital Center in New York City.

Depth Provides a Guide for Best Excision Code

Guideline: If the physician's incision does not go deeper than the fascia, the conservative choice is the appropriate code from CPT's "Integumentary System" section 11400-11471, although the excision needn't necessarily reach the fascia to qualify as a musculoskeletal procedure in all cases.

Example: If the physician's documentation specifies, "Full-thickness excision of 2.5-cm lesion (with margins) from left shoulder with simple closure," the appropriate code choice is 11403 (Excision, benign lesion including margins, except skin tag [unless listed elsewhere], trunk, arms or legs; excised diameter 2.1 to 3.0 cm).

In this case, both the term "full-thickness" (that is, "through the dermis") and "simple closure" should tip you off that the required incision was not very deep.

"During 'full-thickness' excisions, the surgeon removes all layers of skin, and possibly even some subcutaneous tissue, but this does not mean that you should select a musculoskeletal code," says Terri Brame, CPC, CPC-H, principal at BEST Coders. "The excision doesn't extend into the musculoskeletal soft tissues, it just extends to them."

Incision Isn't Always Only Skin-Deep

If the excision goes deeper than the fascia, the removal is definitely not superficial, and the musculoskeletal codes are more appropriate, Weinberg says.

Important: Your physician's documentation must be explicit to support using these codes and should specifically note the incision's depth.

Example 1: If the physician's documentation notes a subcutaneous tumor, you may report 23075 (Excision, soft-tissue tumor, shoulder area; subcutaneous) for removal of lipoma (fatty tumor). This code will pay you about $190.

For even deeper incisions (subfascial or intramuscular), you may choose 23076 (Excision, soft-tissue tumor, shoulder area; deep, subfascial, or intramuscular), which reimburses almost $550, Weinberg says.

Helpful tip: If your physicians often forget about the musculoskeletal codes, you can help them remember by including a list of the codes according to anatomic area on your encounter form to jog their memory, says Patricia Tinker, CPC, clinical practice manager in the department of dermatology at Yale University School of Medicine in New Haven, CT.

Example 2: The physician notes that she excised a subcutaneous tumor from the patient's neck. In this instance, the term "subcutaneous" provides evidence
that you should report 21555 (Excision, tumor, soft tissue of neck or thorax; subcutaneous) rather than 11100 (Biopsy of skin, subcutaneous tissue and/or mucous membrane [including simple closure], unless otherwise listed; single lesion).

Nevertheless, because full-thickness excisions can involve some subcutaneous tissue, you should look closely to be sure that the physician passed the fascia.

Something else to consider: "In my opinion, the appropriate code choice is not simply a matter of depth of excision, but the tissues from which the tumor is being removed," Brame says. "The excision doesn't have to be into the fascia to qualify as a 20000-series code, just into the soft tissues below the skin."

Brame points out that a physician might need to excise a skin lesion from the subcutaneous tissue, just as a soft-tissue lesion excision might also include taking some skin.

"If the surrounding tissues are not part of the integument, then you should choose a musculoskeletal code. One clue for a 20000-series procedure is that the surgeon incises the skin, excises the lesion from underneath and then reapproximates the skin," Brame says.

Documentation essential: When you report a musculoskeletal code, tell the payor that the physician performed a subcutaneous excision reaching below the fascia and that the condition required the physician to perform a more complicated procedure.

Result: The physician deserves more pay for the higher complexity level involved with these deep excisions.

Size Doesn't Matter for Musculoskeletal Excisions

When assigning musculoskeletal codes, you should not consider the size of the lipoma or the excision, as you would when reporting the integumentary codes.

You may not report the musculoskeletal codes, for instance, simply because a lipoma reaches a certain size (for example, more than 5 cm). With musculoskeletal codes, you should only look to the incision's depth, not the tumor's size.

Lesion type can aid with code choice: "You should consider what type of lesion the surgeon removed," Brame says. For instance, a melanoma typically involves skin only, calling for an 11000-series code. A lipoma, however, typically reaches into deeper soft tissue, which could call for a 20000-series code.

Once again, however, "The key is for the physician to describe appropriately the surrounding tissues and the depth to which the lesion is excised," Brame says.

Exceptional Cases Deserve Exceptional Solutions

Although musculoskeletal codes offer increased pay for more complicated, deeper excisions, some exceptions may apply, says Lisa Center, CPC, physician billing certified professional coder with Mt. Carmel Regional Medical Center in Pittsburg, KS.

Example: A patient presents to your practice with a 2-cm lipoma on his forehead that appears to lie under the frontalis muscle.

Take note: If your physician performs a lipoma excision in the flank, you should report 21930 (Excision, tumor, soft tissue of back or flank) because lipomas typically develop in the subcutaneous tissue beneath the skin. Code 21930 will pay you about $420.

This general principle does not apply to lipomas on the face or forehead, however, because in such instances the skin is so close to the bone, Center says.

For the instance above, the only facial musculo-skeletal excision code, other than those involving bone, is 21015 (Radical resection of tumor [e.g., malignant neoplasm], soft tissue of face or scalp). But because the physician did not perform a radical resection, you should not report 21015.

So, you should bill 11442 (Excision, other benign lesion, face ...; excised diameter 1.1 to 2.0 cm) for the lipoma excision on the patient's forehead, which will pay you $170. Although the payment amount is undeniably less, all experts agree that you should only report the code that best describes what your physician documents.